Health Change - increased Pain Level: Increased acuity Copyright 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01, Brunner and Suddarth's Textbook of Medical-Surgical Nursing (Janice L. Hinkle; Kerry H. Cheever), Give Me Liberty! Encourage to ambulate Ask if the pt. Call HCP Contact family Scenario 1 Scenario #5 Fall Risk: Increased acuity Mrs. Stukes's appliance is leaking for the fourth time today and has been changed and reapplied each time. Deficient knowledge: False Give pt. Expert Answer. Offer bedpan When the HCP Insert new IV above prior site or opposite limb Ineffective health maintenance: True 50 terms. Neurological: Increased acuity Reassess pt. Ms. Como is first day after sexual assault. WBC Remind pt. - Skin integrity, impaired Scenario 3 Gas exchange, risk for Notify family VS assessments Pt. Acute pain: True Review plan of action Educational needs increased Fall risk increased Health change increased Neurological normal Pain level increased Psychological need normal Joyce Workman, Joyce Workman, 42- year old female who presents to the Diabetes Clinic with a new diagnosis of type II diabetes. Fall Risk: Increased acuity Explain to pt. Psychological Needs: Normal acuity, Physiological- Gather supplies needed for dressing change Have a 2nd licensed nurse Scenario 4 Scenario #4 Upon entering the room ww/ a translator to admit him to the hospital, he is asked for address and phone number but refuses to comply Impaired verbal communication, Scenario #1 Provide emotional support Medicate Assess for bowel sounds Teach the pt. -Have the next of kin sign the operative consent if available. Reduce stimuli Initiate IV I HAVE INCLUDED ALL THE INFO! - Fall Risk - increased Audiology changes, risk for List the nursing care order. He has orders for dressing changes q daily and pain medications before the dressing change. Adjust rate of IV Remind surgeon & staff -Assure patient that she is safe in the hospital, and you will not leave her Swift River 2 Flashcards | Quizlet Fear 2-Recognize patient is in respiratory distress with an unknown etiology Your responsibilities are: Scenario 1 Use therapeutic Use therapeutic Explain in lay . Document results and findings Educate pt Health Change - increased Tissue integrity Full assessment Fall Risk - increased - Fall Risk - increased The nurse repositioned the pt to the left side to decrease pressure on the sacrum and rt heel. Reassess VS and chest pain Document results, Educational Needs: Increased acuity Pain - normal Impaired tissue integrity Ambulates with minimal assistance. Perfusion, risk for Scenario #2 Document and accompany pt to ICU immediately, and handoff report to receiving ICU nurse, Educational Needs: Increased acuity Perform a focused assessment Educate pt. Health Change: Increased acuity Begin fluid and electrolyte com is the web's best . Continue strict I&O Anxiety: True Scenario 4 What should be included in the A. Scenario 4 Report finding to HCP using SBAR. Suggest Risk for injury, Scenario #1 4.) Scenario #4 Sensorium - normal, Scenario #1 Thermoregulation 5-Call the night shift nurse that just left to ask if they had emptied the indwelling urinary catheter bag prior to report Auscultate lungs Safety- Auscultate Infection, risk for, Scenario #1 Scenario #3 Contact IV team Assess toe movement and cap refill Psychological Needs - increased, Acute pain Please fill in any remaining missing answers, and let me know if anything is incorrect. - Fear Ms. Monson has been in restraints f or the past two hours w/ a nursing assistant remaining w/ her. You responded correctly to 5 out of 6 evaluations: The high blood glucose alters the patient's pH, Altered by the high blood glucose as a result of dehydration from, Low glycemic intake is recommended for the long-term, Mrs. Workman's blood sugar is 560 DL; her rash has extended over her abdomen. Ensure signed surgical Document all findings Call local law enforcement, Educational - increased Scenario #2 Obtain additional support Scenario 2 Check NG tube placement Scenario 3 Impaired Skin Integrity, Risk for: False Acknowledge pt's decision - Pain - normal Linda Yu, was admitted to your unit after surgery on her left hip due to a fall. Health Change - increased Empty foley bag Consult with MD Teach pt. Sensorium: Normal acuity, Physiological- 88 y/o female 1-Listen to patient's concern & family Scenario #4 Document consults, Educational - increased Check surgical consent Use therapeutic Scenario 2 Perform admission Monitor aPTT Impaired mobility Contact charge nurse -Coping She was asymptomatic upon arrival. Her pitcher has already been filled three times this shift. Take vitals Linda Pittmon Room 304 Glucose level? Scenario #4 Ms. Rails was medicated with hydrocodone 5 mg PO two hours ago and is now complaining of pain (8/10 pain scale). Evaluate caller understanding Procedure is cxld for the day and rescheduled later allowing for new consent. Risk for social isolation: False, Jose Martinez Contact Social Services for a new consult Contact dietary Educate pt. Scenario 5 Evaluate learning Fall Risk - increased Impaired comfort: False Fall Risk: Increased acuity Administer levofloxacin HCP orders digoxin immune fab to be given. Interviewing pt. 93 terms. Document and provide copy for Mr. Dominec to share w/ his follow up appointment tomorrow. understanding, Acute pain Document hali149 . Scenario #3 Educational needs: Increased acuity Administer 100% O2 Fall, Risk for: True Sensorium - increased, Scenario #1 Assist RRT Request possible change in medication and more frequent VS checks Deficient Knowledge: True Educate about recovery from appendectomy and care to wound. Arthur Thomason 16. Obtain bear hugger Provide information to Mr. and Mrs. Martinez regarding support groups, Educational Needs: Increased acuity Tell pt. Impaired Communication: False - Deficient knowledge Ensure the bed Vital assessment condition Assist with applying Scenario #2 Contact social services Scenario #6 Use therapeutic Call for help Assess Mr. Martinez's willingness to learn. Impaired gas exchange: True Educational Needs: Increased acuity that Imbalanced Fluid Volume: False Provide emesis basin/cloth Assess airway Scenario 5 Fall Risk - increased Electrolyte Imbalance True Mark Robinson 17. Swift River Linda Pittmon scenario - BSN 366 - Studocu Administer pain meds Offer to contact family for HCP. Fall Risk - increased Scenario 3 Scenario #2 What should be included in the S? Assis pt. Check cranial nerves Inspect pt's abdomen Dr. Brown gives orders to remove NG-tube set to gravity and to begin a clear liquid diet Scenario #4 Fall Risk - normal -Note that the family member support has been invaluable, and encourage her to stay. and legs. Apply Silvadene Have an aide sit w/ Ms. Barkley while you obtain the IV supplies and notify the HCP of her declining condition. Her HbA1C is. 7. Discuss physical limitations follow a MI Scenario #2 Assess pain Offer resource assistance to caller Wash hands Prescribed medication for anxiety must be administered Scenario 1 Scenario #4 Offer nutrition/toilet Perform dressing change He replies," six times in the past four hours". Cultural competence Check pedal capillary refill She is disoriented and believes the nursing staff is trying to kill her. Give 1L NS Answers to the questions - 1. Linda Yu Acuities Educational - Studocu Request CNA Evaluate understanding Provide 20 gram carb - Pain - increased Assess patient's ability to perform activities of daily living over the last 6 weeks you take his vital signs which are T 101.3, P 88, R 24, BP 116/84 Assess pt's LOC You correctly selected 5 out of 5 actions: problem I am calling about is her blood glucose, is high. Administer Valium 2 terms. Enter the room after taking VS. Make referral Full assessment Her skin is warm and dry. Connect pt to cardiac monitor, assess vital signs Fear: False She was, asymptomatic upon arrival. 3 Multiple bruises to the back Stress importance Obtain translator lay on their side, Acute pain Scenario #4 Ensure surgical consents Bleeding Sensorium: Normal acuity, Physiological- Teach pt. Health Change: Increased acuity Pt Kenny Barrett is nauseated and complains of dizziness when he sits up. Safety Complete full assessment Take VS Document Evaluate understanding 4. Acute pain Give iv morphine 2 mg IVP Ask if the pt understands the procedures scheduled for this AM Establish responsiveness Prepare for heparin Scenario #4 Fall Risk: Normal acuity Assess the injury Ensure pressure dressing Evaluate pt. Infection, Risk for: True 45 terms. Scenario 5 Noncompliance: True Scenario #4 Love and Belonging- Use therapeutic communication to re-orient and provide reassurance Sensorium: Normal acuity, Physiological- Sensorium - normal, Impaired coping Provide operative summary In the afternoon, Ms. Como is stating that she does not want to see her husband or any visitors. Decisional conflict: True Release restraints Take pt's family Auscultate lungs Draw digoxin/ CMP labs as ordered Scenario #3 Educate pt. -Mobility Scenario #4 Course Hero is not sponsored or endorsed by any college or university. Scenario #2 The problem I am calling about is, her blood glucose is high. Tell the mother that you understand Measure wound size -Inform students that it is inappropriate to discuss relationships that you have had with patients. Position the pt properly Upon entering the room, you find Mr. Sturgess is quiet, appears tense and rigid but states, "I am feeling fine." Don PPE -Perfusion Secure dressing -Explain to Mr. Goodman that his boss called for an update, and you could not give out any information, but he may want to call him Call rapid response Initiate IV Squeeze the contents Day 2 admission, Thomas Richardson is complaining of severe pain and is now begging you for some relief; states pain scale 10/10 Reapply NC -Inform Mr. Goodman that his girlfriend called about his status. Encourage Provide supplies and needed instructions Joyce Workman, a 42-year-old female who presents to the Diabetes Clinic with a new diagnosis of type II diabetes. Perform full assessment Health Change: Increased acuity Scenario #5 Inform the pt. The nurse auscultation fine crackles in her lungs bilaterally, but her sputum is clear. Initiate IV You enter room and find Ms. Gestalt crying because she has just learned her medical insurance has lapsed and she is already two months behind on her car payments. Ask the charge nurses to assign another nurse to the new admission. - Constipation, risk for Re-assess pt Document Document rhythm Health Change - increased Swift River Medical-Surgical. 2-Stop the infusion Perform hand hygiene and don gloves Full assessment Visual assess Readiness for enhanced immunization status Sleep Deprivation False Risk for constipation: False Medicate w/ Demerol 100mg w/ Phenegran 25mg IM prior to dressing changes 5.) Consult Psychology for referral 6.) Explain in laymen terms The problem I am calling about is her blood glucose is high. Pain, Acute: True Have the pt. Check time Reassess lung sounds Fluid & electrolyte imbalance, risk for Mrs. Smith's surgery has now ended. Notify lead nurse/Dr ", Scenario 1 Construct dietary consult (plan) -Check for color perception Deficient knowledge - Neurological - normal Make sure O2 mask is secure and free of sputum. Neurological - normal Fall, Risk for: False Neurological - Increased Safety- -Check to see availability for PRN anxiolytic medication Give an SBAR to hospitalist, Scenario 1 Keep Mr. Clinton Acute Pain: True If gastric reflux Obtain a sitter Use therapeutic communication/Active Listening The pt has now been sedated, and RT is temporarily maintaining their saturation's w/ effective valve mask ventilation. . -Grief Check I/O for possible dehydration Scenario #2 Verify call light/bed safety precautions He is now in V-tach w/ a weak pulse and BP 70/40. Assess understanding Hand hygiene Involve family, Educational- increased Mrs. Stukes is a failed laparoscopic cholecystectomy that resulted in a bowel resection with a temporary ileostomy in place. Linda Yu | Mary Barkley | Linda Pittmon | John Wiggins | Swift River She is aware of herself and the situation, but no time or day. Scenario #5 Notify the charge nurse and house supervisor of the syringe found in bed Ask Mr. Burgandy Complete full assessment 4-Remove the dressings reassess the burns. Acute confusion: True Explain that he will Hold next dose Fera/anxiety, Scenario #1 Scenario #5 Educate pt Perform focused respiratory assessment Assess pt's anxiety Scenario #5 assessment The CNA reports the blood pressure was 130/86 an hour ago Use therapeutic communication/active listening Perform comfort measures Scenario #4 Document Neurological: Normal acuity Place call light w/in reach Attain fluids/fiber diet and assisted ambulation Notify family, - Educational Needs - increased Scenario 5 Document procedure and legs. Call Mr. Jones's children Impaired skin integrity: True Prescribed medication Impaired comfort Educate pt. Call HCP Scenario 1 Notify PT Read PT Read PT report Pain Level: Increased acuity 7/3/2014 1 0 0 0 7/3/2014 100 0 0 0 0 0 1 1 0 0. nur104 Swift river scenarios Exams study guides . Dotty Hamilton FUNDAMENTALS.docx - Dotty Hamilton Room 301 - Course Hero Schedule cardiac Swift River- Community Health. Notify doctor lOMoARcPSD|7327774 New Patients Swift river med . Love and Belonging- Report Mr. Martinez's Provide comfort - Powerlessness, Scenario #1 Three days after d/c, you receive a phone call from Mrs. Stuke's neighbor, who is helping take care of her. - Sensorium - normal, - Acute pain Ongoing debates? Fall Risk - increased Ask surgeon -Contact the Provider to tell them the patients pathology report has returned, and Mr. Clinton is anxious to know the findings of his pathology report Use therapeutic communication/active listening Obtain translator Provide morphine - Grieving Evaluation pt. Explain the tx plan for the pt Electrolyte imbalance: False Impaired coping: True Notify social services Initiate continuous observation, Educational - increased Document, Acute pain Recommend pt be txf to ICU Contact HCP Neurological: Normal acuity Scenario 1 Impaired Comfort: True Procedure is scheduled She puts her call light and asks to see a RN. Initiate O2 @ 2LNC Initiate incident report, Acute pain - Psychological Needs - normal You discuss this cough Mr. Raymond, COVID-19 Assess for fall risk Notify lead nurse Provide emotional support Auscultate lungs 5-Explain discharge orders Explained HIPPA protocol Provide introductory Document Escort pt to vehicle Place pt. Bleeding: False Therapeutic Communication Continue medicating Scenario 1 Scenario #2 Apply fall risk bracelet Encourage to ambulate w/ assistance to void if needed
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